Surprise Medical Billing happens when a patient, especially in an emergency setting, pays out-of-pocket charges because the provider, ambulatory service, and hospital where he is rushed are out of his network coverage. The No Surprise Act protects these patients from surprise medical billing in emergency settings and provides an estimate to the paying, uninsured patient prior to his encounter. However, not all states are protected by the No Surprise Act and certain ramifications could still happen to those who are covered by it since it has only been this year since this Act started.
How Does Surprise Medical Billing Work?
If a patient pays for health insurance, he is set to be covered for his payments to medical providers who are in-network with his insurance and would pay less if the service is out of that coverage. If a provider, however, sees a patient who is out of that network, that patient is billed more compared to seeing a provider who is within his network. That is basically the gist of how most insurance companies work. This setup is also more controlled if a patient seeks consultation in an office clinic or any scheduled visit. The problem lies in emergency cases where the patient, being in a battle between life and death, cannot and have no time nor autonomy to decide to which hospital he will be brought in. In a quick amount of time, the medical staff should be able to make a decision since after all, the patient’s life is more important than everything else.
A surprise bill is when a patient thinks he is financially covered for his condition but he is not. This usually happens when the patient doesn’t know if his doctor and the hospital, he was brought in are within his network. This puts the patient in a situation where he is charged with extra out-of-network charges costing up to thousands of dollars. The disparity between the doctors’ high payment rate and the low payment rate covered by the insurance is wide which makes the insurance more appealing to the general population.
The No Surprise Act
According to the CMS website, “The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.” It will also resolve any dispute of payments between the providers and the insurance and offers solutions to disputes in the uninsured population who pays out-of-pocket when they receive their bill which is greater than the estimate that they have received.
Beginning January 2022, there are now ways to prevent an individual from getting such a surprise bill which commonly happens in private insurance including an estimate that you can get right before the encounter happens if ever you have no insurance or don’t plan on using it.
New Protection Bans under Surprise Medical Billing
The Center for Medicare summarizes these new protection bans:
1. Ban surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
2. Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.
3. Ban out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility.
4. Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider).
As of December 2021, there are still 17 states that do not offer surprise billing protection. These include Alabama, Alaska, Arkansas, Idaho, Hawaii, Kansas, Kentucky, Louisiana, Montana, Nort Dakota, Oklahoma, South Dakota, South Carolina, Tennessee, Utah, Wisconsin, and Wyoming. The No Surprise Act also amends the Public Health Services Act. The Public Health Services Act which dates back to the 1940s provides legal authority for the department of HHS (Health and Human Services) to respond to public health emergencies.
My RCM Group and its partner providers are aware and up to date with the current development of rules and regulations in the Revenue Cycle Management business. In California, this new federal law protects people from the 2009 California Supreme Ruling called the balance billing wherein the emergency room physician cannot bill HMO patients for out-of-network charges not paid by the insurance company.
References: No Surprises Act | CMS | Federal Register :: Requirements Related to Surprise Billing; Part I | Washington State Letter (cms.gov)
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